ESPEN guidelines on definitions and terminology of clinical nutrition

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ESPEN Guideline
defin
ni b,
, T. H
n, 1, M
van d
x
Departments of Geriatric Medicine, Uppsala University Hospital and Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala
Definition
related concepts and
itional concepts and
ointed a consensus
d e-mail communi-
cation, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round.
85 Uppsala, Sweden.
E-mail addresses: tommy.cederholm@pubcare.uu.se (T. Cederholm), barazzon@units.it (R. Barazzoni), peter.austin@uhs.nhs.uk (P. Austin), peter.ballmer@ksw.ch
(P. Ballmer), biolo@units.it (G. Biolo), bischoff.stephan@uni-hohenheim.de (S.C. Bischoff), compherc@nursing.upenn.edu (C. Compher), isabel_correia@uol.com.br
(I. Correia), t-gucci30219@herb.ocn.ne.jp (T. Higashiguchi), mette.holst@rn.dk (M. Holst), gordon.jensen@med.uvm.edu (G.L. Jensen), ainsleym@nutritioncare.org
(A. Malone), maurizio.muscaritoli@uniroma1.it (M. Muscaritoli), i.nyulasi@alfred.org.au (I. Nyulasi), matthias.pirlich@pgdiakonie.de (M. Pirlich), elisabet.rothenberg@
vgregion.se (E. Rothenberg), karin.schindler@meduniwien.ac.at (K. Schindler), stephane.schneider@unice.fr (S.M. Schneider), m.devanderschueren@vumc.nl (M.A.E. de van
der Schueren), cornel.sieber@fau.de (C. Sieber), valentini@hs-nb.de (L. Valentini), yu-jch@163.com (J.C. Yu), Andre.VanGossum@erasme.ulb.ac.be (A. Van Gossum), pierre.
singer@gmail.com (P. Singer).
1
Contents lists available at ScienceDirect
Clinical Nutrition
journal homepage: ht tp: / /www.elsevier .com/locate/c lnu
Clinical Nutrition 36 (2017) 49e64
Global co-authors contributing late in the process.
* Corresponding author. Clinical Nutrition and Metabolism, Public Health and Caring Sciences, Uppsala University, Uppsala Science Center, Dag Hammarskj€oldsv€ag 14B, 751
University, Uppsala, Sweden
b Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
c Pharmacy Department, Oxford University Hospitals NHS Foundation Trust, United Kingdom
d Department of Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
e Institute of Clinical Medicine, University of Trieste, Trieste, Italy
f Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
g School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
h Department of Surgery, Federal University of Minas Gerais, Belo Horizonte, Brazil
i Department of Surgery and Palliative Medicine, Fujita Health University, School of Medicine, Toyoake, Japan
j Center for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
k The Dean's Office and Department of Medicine, The University of Vermont College of Medicine, Burlington, VT, USA
l Pharmacy Department, Mount Carmel West Hospital, Columbus, OH, USA
m Department of Clinical Medicine, Sapienza University of Rome, Italy
n Nutrition and Dietetics, Alfred Health, Melbourne, Australia
o Department of Internal Medicine, Elisabeth Protestant Hospital, Berlin, Germany
p Department of Food and Meal Science, Kristianstad University, Kristianstad, Sweden
q Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University Vienna, Vienna, Austria
r Department of Gastroenterology and Clinical Nutrition, Archet Hospital, University of Nice Sophia Antipolis, Nice, France
s Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
t Institute for Biomedicine of Ageing, Friedrich-Alexander University Erlangen-Nürnberg, Hospital St. John of Lord, Regensburg, Germany
u Department of Agriculture and Food Sciences, Section of Dietetics, University of Applied Sciences, Neubrandenburg, Germany
v Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing,
China
w Department of Gastroenterology, Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium
x Department of Critical Care, Institute for Nutrition Research, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Petah Tikva 49100 Israel
y Pharmacy Department, University Hospital Southampton NHS Foundation Trust, United Kingdom
z Department of Nutrition, Sports and Health, Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
a r t i c l e i n f o
Article history:
Received 9 September 2016
Accepted 9 September 2016
Keywords:
Terminology
s u m m a r y
Background: A lack of agreement on definitions and terminology used for nutrition-
procedures limits the development of clinical nutrition practice and research.
Objective: This initiative aimed to reach a consensus for terminology for core nutr
procedures.
Methods: The European Society of Clinical Nutrition and Metabolism (ESPEN) app
group of clinical scientists to perform a modified Delphi process that encompasse
A. Van Gossum , P. Singer
a
ESPEN guidelines on
T. Cederholm a, *, R. Barazzo
C. Compher g, 1, I. Correia h, 1
M. Muscaritoli m, I. Nyulasi
S.M. Schneider r, M.A.E. de
w
http://dx.doi.org/10.1016/j.clnu.2016.09.004
0261-5614/© 2016 European Society for Clinical Nutr
itions and terminology of clinical nutrition
P. Austin c, y, P. Ballmer d, G. Biolo e, S.C. Bischoff f,
igashiguchi i, 1, M. Holst j, G.L. Jensen k, 1, A. Malone l, 1,
. Pirlich o, E. Rothenberg p, K. Schindler q,
er Schueren s, z, C. Sieber t, L. Valentini u, J.C. Yu v, 1,
ition and Metabolism. Published by Elsevier Ltd. All rights reserved.
ted
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nut
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jects at nutritional risk followe
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therapy but if inadequate then other forms of medical nutrition therapy, i.e.
aren
of b
lop
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nt, trea
A unification of the appropriate terminolo
legitimacy, credibility and comparability
and could also support future updates of
related classification systems, such as the IC
to improvements in clinical care and th
clinical and scientific nutrition fields.
These aims led the European Society fo
Metabolism (ESPEN) to appoint a Termino
with themission to provide such a set of sta
a main focus on adults.
2. Methodology
roup
SPEN i
al N
Part of the continuous work of E
al care and facilitate research. - Define criteria for nutritional conditions and concepts
2.1. Aim and selection of the expert g
that support improvements in clinic
In 2014 new standards for setting ES
gy would enhance the
of nutritional practices
disease and procedure
D system. This may lead
e advancement of the
r Clinical Nutrition and
logy Consensus Group
ndard terminology with
s to produce guidelines
searches were undertaken in order to create lists of potential
nutritional terms. The terminology was discussed and definitions
determined in face-to-facemeetings andmultiple electronic Delphi
rounds [3].
Additional input was solicited from global contributors whose
suggestions were considered by the writing group during the final
writing phase. They are listed as co-authors due to their substantial
contributions.
2.2. Defined milestones of the consensus process
The overall process was based on five major milestones ac-
cording to the ESPEN Guideline methodology [2] with some
modifications:
- Map and establish taxonomy of nutritional nomenclature
used for nutritional disorders as we
cedures such as screening, assessme
 tment and monitoring. (GESKES). In this DGEM WG-led process thorough literature
sociations, to reach consensus on the terminology and criteria to be
ll as for core nutritional pro-
gates from DGEM as well as from the Austrian Society of Clinical
Nutrition (AKE) and the Swiss Society of Nutritional Medicine
are the basic organization
preferred way of nutrition
enteral tube feeding andp
Conclusion: An agreement
the ESPEN guideline deve
support future global cons
Classification of Disease (
statement will provide the
© 2016 European Socie
1. Introduction
Nutrition plays a pivotal role in life and in medicine. Acute and
chronic diseases in most organ systems have pronounced effects on
food intake and metabolismwith increased catabolism, which lead
to nutrition-related conditions associated with increasedmorbidity
and eventually death. At the other end of the spectrum, diet is a
major determinant of future health, i.e. the absence or post-
ponement of disorders like cardio-vascular disease, diabetes, can-
cer and cognitive disease [1].
In order to handle nutritional challenges during disease, trauma,
rehabilitation, and elderly care as well as for the nutritional pre-
vention of disease it is essential to use professional language and
standard terminology that is founded on evidence and widely
accepted in the professional community. However, this is not al-
ways the case. For example, concepts and terms of nutritional
disorders in the current International Classifications of Diseases
(ICD-10) (http://www.who.int/classifications/icd/en/) may not al-
ways be consistent with modern understanding or terms
commonly used in clinical practice and research.
Therefore, it is important for the nutritional practice and
research communities, including dietitians, nurses, pharmacists,
physicians and scientists as well as their respective scientific as-
Consensus
Malnutrition
Clinical nutrition
Medical nutrition
Results: Five key areas rela
delivery; and products. On
cludes disease-related mal
trition/undernutrition with
obesity) is another core c
associated with malnutriti
T. Cederholm et al. / Clinic50
PEN Guidelines were
teral (intravenous) nutrition, becomes the major way of nutrient delivery.
asic nutritional terminology to be used in clinical practice, research, and
ments has been established. This terminology consensus may help to
us efforts and updates of classification systems such as the International
). The continuous growth of knowledge in all areas addressed in this
ndation for future revisions.
or Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.
established [2]. The presented Guideline standard operating pro-
cedures (SOP) aimed to generate high quality guidelines using a
clear and straight-forward consensus procedure, with one of the
goals to establish international leadership in creating up-to-date
and suitable-for-implementation guidelines. To provide a termi-
nology basis for the guideline development was one of the reasons
for launching this initiative.
An international expert group of experienced clinical scientists
was compiled to form the Terminology Consensus Group and to
undertake a modified Delphi process. The consensus group par-
ticipants, i.e. the authors, were selected to represent various clinical
nutrition fields, as well as various professions; dietitians, nurses,
nutritionists, pharmacists and physicians from clinical and basic
science. It was agreed within the group to base the process on open
e-mail communications, face-to-facemeetings and open and closed
ballots. The purpose was to ensure that communication was
maintained at each milestone (see below) until a consensus was
reached among all participants. Thus, the statements are based on
consensus rather than on systematic literature searches.
This ESPEN Consensus Statement is partly based on the 2014
initiative by the German Society of Nutritional Medicine Working
Group (DGEM WG) and the related publication “Suggestions for
terminology in clinical nutrition” [3]. The WG consisted of dele-
to clinical nutrition were identified: concepts; procedures; organisation;
ore concept of clinical nutrition is malnutrition/undernutrition, which in-
rition (DRM) with (eq. cachexia) and without inflammation, and malnu-
disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and
ept. Sarcopenia and frailty were agreed to be separate conditions often
Examples of nutritional procedures identified include screening for sub-
d by a complete nutritional assessment. Hospital and care facility catering
forms for providing nutrition. Oral nutritional supplementation is the
utrition 36 (2017) 49e64
- Describe general nutritional procedures and processes
- Define organizational forms of providing food and nutritional
care that are available
- Define forms, routes and products for nutrition therapy and
delivery
We resigned to structure the text thoroughly in statements and
T. Cederholm et al. / Clinical N
comments, because it seemed not adequate for the present topics.
Moreover, we did not indicate levels of evidence for the statements,
because for most issues clinical trials are lacking. However, we
indicate the strength of consensus according to the ESPEN classi-
fication (Table 1).
Final consensus beyond the working group was achieved by a
Delphi round using an electronic platform and offering five voting
options (agree, rather agree, indecisive, rather disagree, disagree)
and the possibility to place individual comments. Apart from the
guideline authors, other ESPEN members were invited to partici-
pate within four weeks. A total of 38 experts took part and voted
and provided comments. The main text was divided into 90 para-
graphs open for voting. The voting results are indicated in the text
using the classification of Table 1 and the exact percentage of
agreement (sum of ‘agree’ and ‘rather agree’).
2.3. Map of nutritional terminology
A decision was taken to organize the terminology base into five
categories as described in Table 2.
3. Results
3.1. Nutritional concepts
Nutrition science deals with all aspects of the interaction be-
tween food and nutrients, life, health and disease, and the pro-
cesses by which an organism ingests, absorbs, transports, utilizes
and excretes food substances [4]. [Strong Consensus, 97%
agreement]
Human nutrition addresses the interplay of nutrition in humans.
Preventive nutrition addresses how food intake and nutrients may
affect the risk of developing disease such as cardiovascular disease
(CVD), obesity, type 2 diabetes mellitus (T2DM), dementia and
cancer, either for populations or for individuals. Public health
nutrition targets actions on a population level in order to reduce the
nutrition related major non-communicable diseases (some
mentioned above) (Table 3). [Strong Consensus, 95% agreement]
Clinical nutrition is the focus of the present terminology
consensus initiative, which is the discipline that deals with the
prevention, diagnosis and management of nutritional and meta-
bolic changes related to acute and chronic diseases and conditions
caused by a lack or excess of energy and nutrients. Any nutritional
measure, preventive or curative, targeting individual patients is
clinical nutrition. Clinical nutrition is largely defined by the inter-
action between food deprivation and catabolic processes related to
disease and ageing (Table 4, Fig. 2). Clinical nutrition includes the
nutritional care of subjects with CVD, obesity, T2DM, dyslipidae-
mias, food allergies, intolerances, inborn errors of metabolism as
well as any disease where nutrition plays a role such as cancer,
stroke, cystic fibrosis and many more. Furthermore, clinical
Table 1
Classification of the strength of consensus.
Strong consensus Agreement of >90% of the participants
Consensus Agreement of >75e90% of the participants
Majority agreement Agreement of >50e75% of the participants
No consensus Agreement of <50% of the participants
nutrition encompasses the knowledge and science about body
composition and metabolic disturbances that cause abnormal
changes in body composition and function during acute and
chronic disease. [Consensus, 89% agreement]
Malnutrition/undernutrition, overweight, obesity,micro-
nutrient abnormalities and re-feeding syndrome are clear nutri-
tional disorders, whereas sarcopenia and frailty are nutrition
related conditions with complex and multiple pathogenic back-
grounds (Table 4, Fig. 1).
3.2. Clinical nutrition
3.2.1. Malnutrition. Synonym: undernutrition
Malnutrition can be defined as “a state resulting from lack of
intake or uptake of nutrition that leads to altered body composition
(decreased fat free mass) and body cell mass leading to diminished
physical and mental function and impaired clinical outcome from
disease” [5]. Malnutrition can result from starvation, disease or
advanced ageing (e.g. >80 years), alone or in combination [6].
Basic diagnostic criteria for malnutrition have been defined by
an ESPEN Consensus Statement [7]. Those general criteria are
intended to be applied independent of clinical setting and aeti-
ology. A similar approach to define diagnostic criteria has been
described by a working group of the American Society of Parenteral
and Enteral Nutrition (ASPEN) and the Academy of Nutrition and
Dietetics (Academy) [8]. For details, see respective papers.
[Consensus, 82% agreement]
Briefly, the ESPEN criteria [7] could be summarized that prior to
the diagnosis of malnutrition the criteria for being “at nutritional
risk” according to any validated nutritional risk screening tool must
be fulfilled. Any of two alternative sets of diagnostic criteria will
confirm the diagnosis; i.e. either reduced body mass index (BMI)
<18.5 kg/m2 in accordance with the underweight definition pro-
vided by WHO, or combined weight loss and reduced BMI (age-
dependent cut-offs) or reduced gender-dependent fat free mass
index (FFMI).
Similarly a brief summary of the ASPEN and Academy [8] criteria
for malnutrition is that six malnutrition criteria need to be
considered for the potential diagnosis of malnutrition; i.e. low
energy intake, weight loss, loss of muscle mass, loss of subcu-
taneous fat, fluid accumulation, and hand grip strength, whereof at
least two should be fulfilled for the diagnosis of malnutrition.
There is an obvious need for the global nutrition community to
come together and find a consensus on the crucial issue of which
criteria to use for the malnutrition diagnosis [9]. [Consensus, 85%
agreement]
Subordinate to the general diagnosis of malnutrition are the
aetiology-based types of malnutrition. Table 4 and Fig. 2 describe
and depict disease-related malnutrition with or without inflam-
mation, and malnutrition/undernutrition without disease. Sub-
classifications of malnutrition are crucial for the understanding of
the related complexities and for planning treatment. [Consensus,
85% agreement]
3.2.1.1. Disease-related malnutrition (DRM) with inflammation.
DRM is a specific type of malnutrition caused by a concomitant
disease. Inflammation is an important watershed for malnutrition
aetiology [8,10e12]. Thus, one type of DRM is triggered by a
disease-specific inflammatory response, whereas the other is
linked mainly to non-inflammatory etiologic mechanisms. [Strong
Consensus, 97% agreement]
DRM with inflammation is a catabolic condition characterized
by an inflammatory response, including anorexia and tissue
breakdown, elicited by an underlying disease. The inflammation
utrition 36 (2017) 49e64 51
triggering factors are disease specific, whereas the inflammatory
A special concern is that malnutrition is an emerging occurrence
Table 2
Taxonomy of nutrition terminology, i.e. the structure of nutritional nomenclature as presented in this consensus statement.
A. Classification, definition and diagnostic criteria (when feasible) of core nutritional concepts and nutrition-related disorders (Tables 3 and 4, Figs. 1 and 2)
B. Descriptions of nutritional procedures, and explanations of how assessment, care, therapy, documentation and monitoring are performed (Table 5)
C. Organization and forms of delivery of nutritional care (Table 6)
D. Forms of nutrition therapy, i.e. types and routes (Table 7)
E. Nutritional products, i.e. formulas and types of products for oral, enteral and parenteral use
Table 3
T. Cederholm et al. / Clinical Nutrition 36 (2017) 49e6452
Classification of nutritional concepts.
❖ Human nutrition
➢ Preventive nutrition
▪ Population based public health nutrition
➢ Clinical nutrition
Table 4
Classification of clinical nutrition concepts; i.e. nutrition disorders and nutrition
related conditions.
❖ Clinical nutrition
➢ Malnutrition; Synonym: Undernutrition
▪ Disease-related malnutrition (DRM) with inflammation
� Chronic DRM with inflammation; Synonym: Cachexia
pathways leading to anorexia, reduced food intake, weight loss and
muscle catabolism are fairly consistent across underlying diseases.
The degree of metabolic response induced by the disease de-
termines the catabolic rate and at what point during the disease
trajectory when clinically relevant malnutrition occurs. The role of
inflammation in the development of malnutrition is emphasized in
a non-diagnostic definition, i.e. “malnutrition is a subacute or
chronic state in which a combination of negative energy balance
and varying degrees of inflammatory activity has led to changed
body composition, diminished function and adverse outcomes”
[5,11]. Advanced ageing per se may contribute to the state of
inflammation [13]. Moreover, inactivity and bed rest accelerate
muscle catabolism during DRM with inflammation.
A Cancer cachexia and other disease-specific forms of cachexia
� Acute disease- or injury-related malnutrition
▪ DRM without inflammation. Synonym: Non-cachectic DRM
▪ Malnutrition/undernutrition without disease. Synonym: Non-DRM
� Hunger-related malnutrition
� Socioeconomic or psychologic related malnutrition
➢ Sarcopenia
➢ Frailty
➢ Over-nutrition
▪ Overweight
▪ Obesity
� Sarcopenic obesity
� Central obesity
➢ Micronutrient abnormalities
� Deficiency
� Excess
➢ Refeeding syndrome
[Consensus, 80% agreement]
Fig. 1. Overview of nutrition disorders
among overweight/obese persons with disease, injury, or high
energy poor quality diets in both developed and developing
countries. The underlying general mechanism is a misbalance be-
tween the energy intake, energy expenditure and the quality of the
nutrient intake. Fat mass/adipocytes in excess, especially in the
form of central obesity, are associated with an inflammatory
response that also likely contributes to the state of malnutrition
(see also Section 3.2.4.1.1).
Subordinate concepts to DRM with inflammation are;
- chronic DRM with a milder inflammatory response, and;
- acute disease- or injury-related malnutrition that is character-
ized by a strong inflammatory response (Table 4, Fig. 2)
[8,10e12,14]. [Strong Consensus, 100% agreement]
3.2.1.1.1. Chronic DRM with inflammation. Synonym: cachexia.
The two concepts of chronic DRM with inflammation and cachexia
are exchangeable, although cachexia is often incorrectly perceived
as end-stage malnutrition. Cachexia is traditionally described as “a
complex metabolic syndrome associated with underlying illness
and characterized by loss of muscle mass with or without loss of fat
mass. The prominent feature of cachexia is weight loss in adults”
[15,16]. The cachectic phenotype is characterized by weight loss,
reduced BMI and reduced muscle mass and function in combina-
tionwith an underlying disease that displays biochemical indices of
on-going elevated inflammatory activity. Cachexia occurs
frequently in patients with end-stage organ diseases that are
complicated by catabolic inflammatory responses, which include
cancer, chronic obstructive pulmonary disease (COPD), inflamma-
tory bowel diseases, congestive heart failure, chronic kidney dis-
ease and other end-stage organ diseases. The systemic
inflammation that drives the catabolism of such disorders is usually
of milder character; i.e. for example serum concentrations of C-reactive proteins (CRP) seldom exceed 40 mg/L, although inflam-
matory flaresmay occur during disease exacerbations. CRP >5mg/L
is suggested as a lower limit to define relevant inflammation in this
scenario; although other CRP cut-off levels for various given
methods, as well as other biochemical inflammatory markers,
could be considered.
Cachexia, as described in cancer, can progressively develop
through various stages: pre-cachexia; cachexia; and refractory
cachexia [16,17]. Cancer cachexia, which is a specific form of chronic
DRM with inflammation, is according to Fearon et al. [17] defined
by either weight loss >5% alone, or weight loss >2% if BMI is
and nutrition-related conditions.
non-inflammation related mechanisms. Inflammation may for
ition
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reduced (<20 kg/m2) or fat free mass (FFM) is reduced; i.e.
appendicular skeletal muscle mass index <7.2 kg/m2 (men) or
<5.5 kg/m2 (women). [Strong Consensus, 93% agreement]
A similar concept known as cardiac cachexia has been estab-
lished by Anker et al. [18] for patients with chronic heart failure
which is based on non-intentional and non-oedematous weight
loss >7.5% of the premorbid normal weight. Cardiac cachexia is
associated with abnormal neuroendocrine and immunologic
function and impaired prognosis independent of age and severity of
disease.
Patients with pre-cachexia are at risk of malnutrition due to the
inflammatory response elicited by the underlying chronic disease
[16,17] (see Section 3.3.1.1).
Diagnostic criteria for chronic DRMwith inflammation/cachexia
are suggested to be the same as those for malnutrition combined
with the simultaneous presence of an underlying disease and
biochemical indices of either ongoing or recurrent inflammation.
Biochemical indicators of inflammation include elevated serum
CRP concentrations and/or reduced serum concentrations of albu-
min. [Strong Consensus, 97% agreement]
3.2.1.1.2. Acute disease- or injury-related malnutrition.
Patients in an Intensive Care Unit (ICU) with acute disease or
trauma (e.g. major infections, burns, closed head injury) or those
after major surgical procedures display specific nutritional chal-
lenges with high risk of consequent malnutrition due to their often
Fig. 2. Diagnoses tree of malnutrition; from at risk for malnutr
T. Cederholm et al. / Clinic
highly pronounced stress metabolism [14]. The combined action of
high pro-inflammatory cytokine activity, increased corticosteroid
and catecholamine release, resistance to insulin and other growth
hormones, bed rest and no or reduced food intake pave the way for
a fast decline of body energy and nutrient stores. Such patients
need to have nutrition care plans initiated irrespective of body
weight or any anthropometric measurement.
There are no agreed objective criteria for malnutrition in the ICU
patient, but the obvious catabolic clinical picture always needs to be
managed from a nutritional point of view. [Strong Consensus, 97%
agreement]
3.2.1.2. DRM without inflammation. Synonym: non-cachectic DRM.
DRM without inflammation/non-cachectic DRM is a form of
disease-triggered malnutrition in which inflammation is not
among the etiologic mechanisms. These alternative mechanisms
could include dysphagia resulting from upper digestive obstruc-
tion, neurologic disorders such as stroke, Parkinson's disease,
amyotrophic lateral sclerosis (ALS) or dementia/cognitive
dysfunction. Psychiatric conditions like anorexia nervosa and
some of the described diseases be involved in the initial phase of
the malnutrition trajectory, but does not have a clinically relevant
impact in the later phases of the malnutrition process. For some
diseases, e.g. Crohn's disease, patients may oscillate between
malnutrition with and without inflammation.
Diagnostic criteria for DRM without inflammation/non-
cachectic DRM are identical with those for malnutrition, com-
bined with an underlying disease but with no biochemical indices
of present or recurrent inflammation. [Strong Consensus, 94%
agreement]
3.2.1.3. Malnutrition/undernutrition without disease. Synonym: Non-
DRM. Whilst DRM is the principal form of malnutrition in affluent
societies, hunger is still the principal cause of malnutrition in poor
developing countries. Hunger is mainly of non-DRM origin. Within
the concept of non-DRM there are also miscellaneous socioeco-
nomic/psychological mechanisms operating which are unrelated to
depression, or malabsorption due to intestinal disorders such as
short bowel syndrome (for example after bowel resection due to
mesenteric infarction), are other mechanisms for the development
of non-inflammation driven DRM. Advanced ageing per se may
contribute to DRM without inflammation by anorexia; denoted
“anorexia of ageing” [19] (see Section 3.2.3), that is caused also by
, basic definition of malnutrition to aetiology-based diagnoses
utrition 36 (2017) 49e64 53
availability of food. As indicated advanced ageingmay contribute to
any form of malnutrition/undernutrition.
The metabolic phenotype and the principles for treatment of
non-DRM are in many respects similar for undernutrition/starva-
tion due to hunger, socioeconomic/psychological factors, or DRM
without inflammation. [Strong Consensus, 97% agreement]
3.2.1.3.1. Hunger-related malnutrition. Hunger-related malnu-
trition is caused by deprivation of food, and is mainly appearing in
poor developing countries and can manifest through famine due to
natural disasters like droughts or flooding.
Diagnostic criteria for hunger-related malnutrition are the same
as those for malnutrition when hunger or food deprivation in the
absence of disease is the clear cause for the condition. [Strong
Consensus, 97% agreement]
3.2.1.3.2. Socioeconomic or psychologic related malnutrition.
Non-DRM, other than hunger-related malnutrition as described
abovemay emerge during difficult situations such as poverty, social
inequities, poor care, mourning, poor dentition, self-neglect, im-
prisonments or hunger strike. Such conditions have effect not only
on the energy intake, but also on the quality of the food intake.
[Strong Consensus, 97% agreement]
al N
3.2.2. Sarcopenia
Sarcopenia is a syndrome of its own characterized by the pro-
gressive and generalised loss of skeletal muscle mass, strength and
function (performance) with a consequent risk of adverse out-
comes [20e22]. Whilst often a phenomenon of the ageing pro-
cesses (primary sarcopenia) preceding the onset of frailty (see
below), it may also result from pathogenic mechanisms (secondary
sarcopenia) [20] that are disease-related, activity-related (e.g.
disuse) or nutrition-related (e.g. protein deficiency).
Diagnostic criteria for sarcopenia have not been firmly estab-
lished to date. The ESPEN endorsed recommendations of the Eu-
ropeanWorking Group on Sarcopenia in Older Persons [20], as well
as the statement from the ESPEN Special Interests Groups of
Cachexia in Chronic Disease and Nutrition in Geriatrics [16] indicate
an algorithm based on loss of muscle mass and strength and/or
function. Muscle mass can be estimated by any validated technique,
which in clinical practice usually involves dual x-ray absorptiom-
etry (DXA), bio-electric impedance analysis (BIA) or computed to-
mography (CT) scanning. For example, reduced muscle mass could
be indicated by an appendicular skeletal muscle mass index
<7.26 kg/m2 (men) and <5.5 kg/m2 (women) [20]. Reduced muscle
function may be designated by reduced gait speed or failure of the
chair standing tests (which tests lower extremities). Practical
diagnostic cut-offs for gait speed are considered to be: <0.8 m/s
[20] or <1.0 m/s [21]. Reduced muscle strength may also be
measured by handgrip strength; suggested cut-off points are
<20 kg for women and <30 kg for men [20]. [Strong Consensus, 94%
agreement]
3.2.2.1. Sarcopenic obesity e see section 3.2.4.1.1. ,
3.2.3. Frailty
The definitionof frailty is evolving, as this emerging concept is
still under discussion among experts in gerontology and geriatrics
[23]. The general perception is that frailty is a state of vulnerability
and non-resilience with limited reserve capacity in major organ
systems. This leads to reduced capability towithstand stress such as
trauma or disease and thus frailty is a risk factor for dependence
and disability. Frailty is mainly related to advanced age but never-
theless it is considered to be modifiable by lifestyle interventions.
The condition contains nutrition-related components; e.g. weight
loss, and is linked to sarcopenia [24]. In that capacity physical frailty
merits to be listed among nutrition-related conditions. Anorexia of
ageing is an unintentional decline in food intake caused by factors
such as altered hormonal and neuro-transmitter balance affecting
hunger and satiety whichmay contribute to age-relatedweight loss
[19]. Financial constraints, loneliness, depression, difficulties with
chewing (including poor dentition) and presbyphagia (changes in
the swallowing mechanism) are further examples of conditions
that may contribute to malnutrition and thus to frailty in the more
elderly.
Several sets of diagnostic criteria for physical frailty have been
suggested. The phenotype of frailty as defined by Fried et al. [25]
included the fulfilment of three out of five criteria: weight loss;
exhaustion (fatigue); low physical activity; slowness (e.g. reduced
gait speed); and weakness (e.g. low grip strength). Detailed cut-off
values for each measurement have been suggested, but consensus
is yet not achieved [26]. [Strong Consensus, 97% agreement]
3.2.4. Over-nutrition
3.2.4.1. Overweight and obesity. Overweight and obesity are
defined as abnormal or excessive fat accumulation that may impair
health [27]. Classification of overweight and obesity in adults is
T. Cederholm et al. / Clinic54
achieved through the use of body mass index (BMI), which is a
simple index of weight-for-height. It is defined as a person's weight
in kilograms divided by the square of their height in meters.
Accordingly,
- BMI between 25 and 30 kg/m2 implies overweight
- BMI greater than or equal to 30 kg/m2 implies obesity
Obesity can be further classified in grades according to BMI
Obesity grade I: BMI 30 e <35 kg/m2
Obesity grade II: BMI 35 e <40 kg/m2
Obesity grade III: BMI �40 kg/m2
Grading of obesity could be adjusted for race/ethnicity. Thus,
corresponding lower cut-offs have been proposed for Asian pop-
ulations both for diagnosis of obesity [28,29], and for risk of
obesity-associated complications [30].
As previously mentioned in Section 3.2.1.1 it is also common for
overweight/obese persons to be malnourished in the setting of
disease or injury or consumption of high energy poor quality diets,
such that over-nutrition and malnutrition may exist simulta-
neously. [Strong Consensus, 94% agreement]
3.2.4.1.1. Sarcopenic obesity. Sarcopenic obesity is defined as
obesity in combination with sarcopenia that occurs for example in
older individuals, in those with T2DM, COPD, and in obese patients
with malignant disorders and post organ transplantations. Mech-
anisms include inflammation and/or inactivity induced muscle
catabolism in obese patients [31,32]. The condition can occur
virtually at all ages.
For body composition measurement in clinical practice DXA
might be most accurate in obese individuals. Computed tomogra-
phy (CT) scan is an alternative emerging technology for the mea-
surement of muscle mass. There is no clear consensus about normal
ranges for fat-freemass index (FFMI, fat-freemass/height2), and the
uncertainty is even larger for the obese individual, since the normal
ranges might be different from the lean population [33]. Low FFMI
and high FMI was associated with poor outcome in terms of length
of hospital stay when compared with normal FFMI or FMI, when
using BIA in a large cohort of hospital patients [34].
Currently, there are no commonly accepted criteria for sarco-
penic obesity beyond those for sarcopenia and obesity separately.
Muscle function can be assessed by strength and power as for
sarcopenia, i.e. muscle strength by using hand grip measurements
or chair stand tests. Muscle power could be measured by gait
speed, or by assessing patient autonomy by Activity of Daily
Living (ADL) scores andmobility by for example the Short Physical
Performance Battery (SPPB) [35]. [Strong Consensus, 97%
agreement]
3.2.4.1.2. Central obesity. Accumulation of intraabdominal fat is
associated with higher metabolic and cardiovascular disease risk
[27], which includes insulin resistance, T2DM, dyslipidaemia and
hypertension. These associations are most relevant in moderately
obese patients (BMI<35) as well as in non-obese individuals cate-
gorized as overweight (i.e. with BMI 25- 30). The presence of cen-
tral obesity (also known as abdominal, visceral, upper-body or
android obesity) can be clinically defined by increased waist
circumference (WC) measured in the mid-horizontal plane be-
tween the superior iliac crest and the lower margin of the last rib
[36]. Recent European consensus statements define abdominal
obesity by WC �94 cm for men, and �80 cm for women [37],
whereas US Guidelines indicate corresponding definitions of
�102 cm and �88 cm respectively [38]. Like for obesity ethnic and
regionally adapted cut-offs are also available.
Intraabdominal fat can also be assessed by imaging techniques
utrition 36 (2017) 49e64
but these are costly and not routinely available, and in addition
al N
there are no clearly defined values for assessment. [Strong
Consensus, 97% agreement]
3.2.5. Micronutrient abnormalities
Micronutrient abnormalities can involve a deficiency or excess
of one or more vitamins, trace elements or minerals. Abnormalities
may result from changes in food intake, absorption, losses, re-
quirements and intake of medicines, alone or in combinations. In-
dividual requirements can vary according to age and diet (foods
may be fortified) as well as the presence of disease or injury. A
complete nutritional assessment is important when assessing
micronutrient status since specific micronutrient deficiencies are
frequently associated with undernutrition [39]. Analysis of dietary
records may suggest potential deficiency or excess based on rec-
ommended dietary allowances (RDA). RDAs are defined for healthy
populations and may therefore not always match the needs of in-
dividuals with disease.
The laboratory assessment of micronutrient abnormalities is
complex since measured concentrations do not necessarily reflect
adequacy, for example an acute phase response can affect the
concentration reported. Laboratory testing of micronutrient status
is generally not routinely undertaken unless there is a specific acute
concern, use of restrictive dietary regimes, a prolonged history of
undernutrition or during supplementation. [Strong Consensus,
100% agreement]
3.2.5.1. Micronutrient deficiency. Micronutrient deficiency occurs
when there is a deficit of one or more micronutrient/s compared to
requirements [40]. Specific micronutrient deficiencies can have
dramatic consequences such as rickets and osteoporosis from
vitamin D deficiency, night blindness from vitamin A deficiency, or
beriberi or Wernicke-Korsakov syndrome due to thiamine deple-
tion. But micronutrient deficiencies can also lead to impaired
function that may be less obvious such as poor wound healing or
increased susceptibility to infection. These more subtle effects may
be overlooked in clinical practice, for example after bariatric sur-
gery [41].
Laboratory assessed concentrations may be valuable when there
is concern about long-standing deficiency following clinical
assessment or when infrequent periodic checks are required for
long-term nutritional supplementation. [Strong Consensus, 94%
agreement]3.2.5.2. Micronutrient excess. Micronutrient excess occurs when
there is too much of one or more micronutrients compared to re-
quirements [42]. Micronutrient excess can lead to specific symp-
toms such as the movement disorders of manganese accumulation
and subsequent toxicity, or to more general symptoms such as skin
irritation and rashes from excessive niacin, hip fracture risk ensuing
from excessive retinol intake or peripheral neuropathy following
long lasting high intake of vitamin B6. Overprovision of micro-
nutrients can result from incorrect prescription.
Clinical assessment and diagnosis play key roles in determining
micronutrient excess, partly due to the difficulties with laboratory
analyses. For patients on long-term nutritional supplementation
laboratory monitoring every 6 months can be recommended [43].
[Strong Consensus, 94% agreement]
3.2.6. Refeeding syndrome
Refeeding syndrome (RS) is a severe disruption in electrolyte or
fluid balance that is precipitated in malnourished subjects when
feeding (oral, enteral or parenteral nutrition) is begun too aggres-
sively after a period of inadequate nutrition. Patients at high risk are
those with chronic alcoholism, subjects with severe chronic un-
T. Cederholm et al. / Clinic
dernutrition, anorexia nervosa, or depleted patients with acute
illness. Clinical symptoms can include fluid retention with pe-
ripheral oedema, congestive heart failure, cardiac arrhythmia, res-
piratory failure, delirium, encephalopathy, and other severe organ
dysfunctions. RS usually occurs within the first four days after
nutrition therapy is commenced. Hypophosphatemia that drives
many of the medical complications of RS may be the most frequent
electrolyte disturbance, with or without hypokalaemia, hypomag-
nesemia and hypocalcaemia [44].
Diagnostic criteria for RS include fluid imbalance, disturbed
glucose homeostasis, hyperlactatemia suggesting vitamin B1 defi-
ciency, but most frequently hypophosphatemia, hypomagnesemia
and hypokalaemia. Screening for patients at risk of RS includes one
or more of the following: BMI<16 kg/m2; unintentional weight loss
>15% in 3e6 months; little or no intake for >10 days; or low po-
tassium, phosphate and magnesium before feeding. If two or more
of the following factors exist a risk of RS should also be considered:
BMI <18.5 kg/m2; unintentional weight loss >10% in 3e6 months;
little or no nutritional intake for >5 days; or a history of alcohol
misuse or chronic drug use (insulin, antacids, diuretics) [43,45].
[Strong Consensus, 97% agreement]
3.3. Nutritional procedures - the nutrition care process
Nutritional care should be provided in a systematic sequence
that involves distinct interrelated steps and this systematic
sequence is called a nutrition care process (Table 5).
3.3.1. Malnutrition risk screening
Risk screening is a rapid process performed to identify subjects
at nutritional risk, and should be performed using an appropriate
validated tool in all subjects that come in contact with healthcare
services. Depending on the care setting, screening should be per-
formed within the first 24e48 h after first contact and thereafter at
regular intervals. Subjects identified as at risk need to undergo
nutritional assessment (see Section 3.3.2). There are several risk
screening tools in use, and many are validated for predicting
outcome, whereas some identify subjects that will benefit from
nutrition therapy.
It is important to underscore that “risk of malnutrition” as it is
identified by the screening tools (usually combining weight loss,
reduced food intake and disease activity) is in itself a condition
related to increased morbidity and mortality.
ESPEN suggests the use of Nutrition Risk Screening-2002 (NRS-
2002) and the Malnutrition Universal Screening Tool (MUST). For
older persons ESPEN recommends the use of the Mini Nutritional
Assessment (MNA) either in its full or short form (MNA-SF). These
tools are all compiled of various combinations of registered or
measured BMI, weight loss, food intake, disease severity and age.
Other validated tools that combine similar variables and which are
frequently used include the Malnutrition Screening Tool (MST) and
the Short Nutritional Assessment Questionnaire (SNAQ). Malnu-
trition risk screening tools are well described in the literature and
will not be further described here [46e50]. [Strong Consensus, 97%
agreement]
3.3.1.1. Pre-cachexia screening. The process to screen for pre-
cachexia, a state that may precede cachexia, is performed in or-
der to launch measures that may prevent or postpone the devel-
opment of cachexia as early as possible. The procedure refers
mainly but not exclusively to patients with cancer [16], and could
be regarded as a form of DRM with inflammation risk screening
procedure (see Section 3.3.1).
Pre-cachexia is diagnosed in patients affected by chronic dis-
eases, including cancer, based on the concomitant presence of
utrition 36 (2017) 49e64 55
weight loss <5%, anorexia and metabolic disturbances related to
systemic inflammation as revealed by for example increased serum
CRP levels [16,17]. [Strong Consensus, 97% agreement]
3.3.1.2. Sarcopenia screening. The ESPEN endorsed statement from
the European Working Group on Sarcopenia in Older Persons rec-
ommends screening for sarcopenia from age 65 years onwards by
measuring gait speed and then, based on the results handgrip
strength and/or muscle mass [20]. [Strong Consensus, 100%
agreement]
the basis for the diagnosis decision (see Section 3.2.1), as well as for
further actions including nutritional treatment. Predefined assess-
� Instructions for implementing the specified form of nutrition
- Biochemistry: There are no good biochemical markers of the
T. Cederholm et al. / Clinical N56
ment tools like Subjective Global Assessment (SGA) [51], Patient-
Generated (PG)SGA and Mini Nutritional Assessment (MNA)
could be used to facilitate the assessment procedure.
Assessment of the nutritional status comprehends information
on body weight, body height, body mass index (kg/m2), body
composition (see Section 3.3.6.2) and biochemical indices (see
Section 3.3.6.3). [Strong Consensus, 97% agreement]
Objectives of the assessment are to evaluate the subject at risk
according to the following measures:
- A medical history should be taken, and physical examinations
and biochemical analyses should be performed in order to
decide the underlying disease or condition that may cause the
potential state of malnutrition.
- Social and psychological history is taken to establish potential
effects of living conditions, loneliness and depression on nutri-
tional needs, and whether input from other professional groups
may be of benefit.
- A nutrition history, including limitations in food intake, should
be taken and examinations and observations should be per-
formed in order to decide the underlying nutritional causes, and
to identify major nutritional obstacles and calculate nutritional
needs.
- Energy and fluid needs are determined by indirect calorimetry
(energy expenditure) or calculated according to validated
equations.
- Protein needs are established in the range from 0.8 g/kg/day
(healthy adults) and up to 1.5 g/kg/day (in some cases even
higher) according to age, disease and degree of protein deple-
tion [52].
- Micronutrient needs should be determined according to pre-
vailing recommendations and the clinical picture. [Strong
Consensus, 94% agreement]
3.3.3. Diagnostic procedure
When the nutrition risk screening identifies subjects at risk, the
nutritional assessment will provide the basis for the diagnosis of
Table 5
The nutrition care process.
� Malnutrition risk screening
� Nutritional assessment
� Diagnostic procedure
� Nutritional care plan
� Nutritional care
➢ Nutrition therapy
� Monitoring and evaluating the effects of nutritionalcare and therapy
� Documentation
3.3.2. Nutritional assessment
Nutritional assessment should be performed in all subjects
identified as being at risk by nutritional risk screening, andwill give
[Strong Consensus, 97% agreement]
nutritional status. Plasma albumin and transthyretin/pre-
albumin concentrations may be used mainly to indicate and
monitor catabolic activity. Their validity as nutrition indicators
is low in view of their perturbation by inflammation.
- Function: e.g. hand grip strength (HGS), chair rise tests and gait
speed, either alone or combined in the Short Physical Perfor-
3.3.5.1. Nutrition therapy. Nutrition therapy describes how nutri-
ents are provided to treat any nutritional-related condition.
Nutrition or nutrients can be provided orally (regular diet, thera-
peutic diet, e.g. fortified food, oral nutritional supplements), via
enteral tube-feeding or as parenteral nutrition to prevent or treat
malnutrition in an individualized way. [Strong Consensus, 97%
agreement]
3.3.6. Monitoring
Monitoring of nutrition therapy is a measure to check and adjust
that nutrition delivery is in progress and nutrition intake or pro-
vision is sufficient, as well as to assure tolerance and that goals and
expected outcomes are achieved. The monitoring procedures
require an individual plan where nutrition goals are defined.
[Strong Consensus, 97% agreement]
Fact Box: Monitoring plan of nutritional care and therapy.
- Nutrition provision and intake: Are calculated requirements of
fluid, energy and protein met?
- Weight, anthropometry, body composition: Does e.g. weight, fat
free mass (FFM) or fat mass (FM) change as expected?
3.3.5. Nutritional care
Nutritional care is an overarching term to describe the form of
nutrition, nutrient delivery and the system of education that is
required for meal service or to treat any nutrition-related condition
in both preventive nutrition and clinical nutrition. [Strong
Consensus, 100% agreement]
therapy
� The most appropriate route of administration and method of
nutrition access
� Anticipated duration of therapy
� Monitoring and assessment parameters
� Discharge planning and training at home (if appropriate)
[Strong Consensus, 100% agreement]
malnutrition according to the nutrition diagnostic procedure out-
lined in Section 3.3.1. This part of the assessment procedure is often
neglected, mainly due to the absence of a global consensus for
diagnostic criteria and their cut-offs [7e9]. [Strong Consensus, 97%
agreement]
3.3.4. Nutritional care plan
The nutritional care plan is a scheme for nutrition therapy based
on the results of the assessment. This plan should be developed by a
multi/interdisciplinary team together with the patient and his/her
carer in order to achieve patient centered treatment goals. A
comprehensive nutritional care plan defines the rationale, explains
the nutrition therapy and provides suggestions for monitoring the
efficacy of the plan and reassessment.
The nutritional care plan includes information on:
� Energy, nutrient and fluid requirements
� Measureable nutrition goals (immediate and long-term)
utrition 36 (2017) 49e64
mance Battery (SPPB) [35] could be used.
al N
- Quality of life (QoL): e.g. EQ-5D or HRQOL, or other tools rele-
vant to the diagnosis, could be used.
It should be emphasized that current biochemistry, functional
and QoL measurements may not be sensitive enough to capture
relevant changes of the nutritional status. [Strong Consensus, 97%
agreement]
3.3.6.1. Nutrition intake. In the hospital setting, recording of
nutrition intake can be performed at the bedside by nurses or as-
sistant nurses, using plate diagram sheets that have proven clini-
cally useful [53,54], or using self-recorded diary by patients
themselves [55]. Amount of food consumption could be estimated
by food records during 2e4 days [56,57]. Food weight record, i.e. to
weigh each food item before and after food consumption, is difficult
to implement in clinical practice, but is often used in research.
Modern digital technologies may provide new means to establish
food intake [58]. [Strong Consensus, 100% agreement]
3.3.6.2. Weight and body composition. Monitoring of weight during
hospitalization may not be sensitive due to disease or therapy
related shifts in fluid balance. Nevertheless, weight should be
recorded one to three times per week whilst a patient is in hospital
with a decreasing frequency when in a stable condition. If the pa-
tient is undergoing ambulatory treatment the type of underlying
condition will indicate the interval of weight measurement
required. Regular weight measurements are not useful for patients
in late palliative phases, or in any subject at end of life.
FFM and FM are estimated by bio-impedance analysis (BIA) or
DXA-scan, but subject to the same limitations as weight
measurements. Standard anthropometric measurements, such as
mid-arm-circumference, calf-circumference or skinfold thickness
are potential alternatives although subject to measurement
variability [59]. [Strong Consensus, 93% agreement]
BIA is a quick non-invasive method to estimate body composi-
tion, but requires stringent standard procedures such as a fast for at
least 2 h and urination before the test is carried out [60,61]. Single
frequency-BIA (SF-BIA) is commonly used to estimate total body
water (TBW) and fat free mass (FFM) with a validated formula.
Multi frequency-BIA (MFBIA) and bioelectrical impedance spec-
troscopy (BIS) calculate intracellular water (ICW), extracellular
water (ECW), TBWand FFM. BIS offers information of ICWand ECW
distribution. From these FFM is predicted. BIA-derived phase angle
has a strong prognostic value [62]. [Strong Consensus, 97%
agreement]
DXA is regarded as a more accurate method on an individual
level. It is an accepted reference method to evaluate BIS. DXA gives
information on FM, lean soft tissue (LST) and bone mineral content
(BMC). The radiation dose of a single DEXA measurement is
dependent on the device and the age of the patient, but is low and
therefore the expected lifetime risk of fatal cancer is negligible.
However, DEXA is not recommended for pregnant women. [Strong
Consensus, 100% agreement]
Computerized tomography (CT) imaging is being increasingly
used to evaluate muscle mass depletion [63]. CT scanning is often
performed in patients with malignant disorders, thus providing
images that could be used for the evaluation of muscle mass. The
fact that reference values are scarce for this technique will reduce
its validity until such data are available. [Strong Consensus, 97%
agreement]
3.3.6.3. Biochemical indices. Biochemical markers, e.g. serum con-
centrations of visceral proteins, should not be used as indicators of
a patient's nutritional status. Monitoring visceral protein levels
T. Cederholm et al. / Clinic
during refeeding in DRM with inflammation may be helpful,
keeping in mind that variations are reflecting the degree of catab-
olism/inflammation rather than nutritional recovery [64]. Under
some circumstances, and taking into account each protein's half-
life, levels of albumin (T½ 21 days) and transthyretin/prealbumin
(T½ 3 days) may be monitored for long- and short-term effects [65].
Especially in severely malnourished subjects where inflammation
is not present, visceral protein levels may improve with nutritional
resuscitation [64]. C-reactive protein serum concentrations are
suggested for monitoring inflammatory activity (see also Section
3.2.1.1.1). [Strong Consensus, 100% agreement]
3.3.6.4. Physical function. Measurement of physical function is
crude, but nevertheless a relevant way to monitor nutritional care
and therapy. Hand grip strength by a hand held dynamometer, gait
speed or chair rise tests are fairly easy to undertake for the mea-
surement of changes in muscle function sensitive to nutrition in-
terventions [66e68].Composite functional scores, like the Short
Physical Performance Battery (SPPB) [35], De Morton Mobility In-
dex [69] or the Barthel Index [70] may also be relevant functional
measures. [Strong Consensus, 100% agreement]
3.3.6.5. Quality of life. Health related quality of life assessed by a
validated tool; e.g. EQ-5D [71] may be used as a crude non-specific
measure of changes in nutritional status, and as an indicator of
reduced food intake [72]. [Strong Consensus, 97% agreement]
3.3.7. Documentation
Nutritional care given has to be communicated at discharge
from a healthcare facility to the next caregiver in order to secure
continuation of the nutritional care and support. Documentation in
medical, dietetic and care records should be provided for
nutritional risk screening, diagnosis, assessment of risk factors,
nutritional requirements, nutrition therapy, goals and outcomes for
nutrition therapy, including estimated time to reach goals, as well a
note of who is responsible for the follow-up [73]. The documen-
tation should also provide information on need for help for servings
and eating, need for oral care and which are the preferred meals
[74] [Strong Consensus, 100% agreement]
3.4. Organization of nutritional care at hospitals and care facilities
Nutritional care in some form is provided to all patients within a
hospital or care facility. Depending on the type and severity of the
nutritional problems of the patients, the structure and organization
of the nutritional care needs to be adapted (Table 6).
3.4.1. Care catering (hospital catering)
Care catering or hospital catering is the provision of menu ser-
vices (in-house or outsourced) in health care facilities. The mini-
mum requirements of hospital and care catering are to serve a
variety of foods that are suitable and adapted to all types of patients
with a variety of energy and nutrient densities. Special diets, food
texture, allergies and specific cultural aspects have to be considered
at all times. For patients with, or at risk, for malnutrition, informed
choices with respect to food items and portion sizes have to be
ensured. Twenty-four-hour access to nutritionally relevant and
well-prepared food should be mandatory, and served portions
must appear appetizing for the individual. Energy dense small size
portions should be available as an option for patients at nutritional
risk. [Strong Consensus, 97% agreement]
3.4.2. Nutrition steering committee (NSC)
A NSC is a committee at a hospital or care facility of a mixed
interdisciplinary composition including directors, managers, health
utrition 36 (2017) 49e64 57
professionals and catering staff.
The main objective of a NSC is to set standards for the structure,
procedures and management of clinical nutrition at the relevant
institutions. Depending on the legal status of the NSC (mainly
decided by the care facility management) it may also be responsible
for the audit of the nutritional care and responding to nutritional
incidents. [Strong Consensus, 97% agreement]
3.4.3. Nutrition support team (NST)
problems. Moreover, the objective includes ensuring that all
focussed teams linked to specific care facilities could also be
objective to serve and support the staff as well as individual pa-
T. Cederholm et al. / Clinical N58
Table 6
Organizational forms of providing nutritional care and support.
� Care catering/Hospital catering
� Nutrition Steering Committee
� Nutrition Support Team
� Disease-specific Support Teams
� Clinical Nutrition Care Unit
� Clinical Nutrition Support Unit
tients according to nutritional issues. Hospital dietitians could be
organized in independent administrative units, or be formally in-
tegrated parts of the multi-disciplinary team at department level.
[Strong Consensus, 93% agreement]
3.4.6. Clinical nutrition support unit
Based on hospital's organization, patients that require nutrition
therapy or receive home artificial/medical nutrition who develop
complications such as central line infection can be hospitalized in
specific clinical nutrition support wards managed by a multidisci-
plinary team of specialized physicians, nurses, dietitians and
pharmacists. [Strong Consensus, 93% agreement]
available. For example, an Obesity team is a multidisciplinary team
of specialists consisting of physicians, dietitians, nurses, physio-
therapists, behavioural therapist (psychologist/psychiatrist) as well
as other relevant professionals. The Obesity team provides
personalized, patient-centred and comprehensive weight man-
agement/lifestyle programmes which take into account the
comorbidities of the obese patients. The Obesity team should also
assist “bariatric surgery” services for pre- and post-operative care.
Similar team approaches are relevant for example for diabetes,
chronic obstructive pulmonary disease, cancer and palliative care.
[Strong Consensus, 100% agreement]
3.4.5. Clinical nutrition care unit
In many hospitals across different countries, dietitians represent
a core of nutrition professionals at the hospital, with the specific
nutrition therapy utilises state-of-the-art knowledge and tech-
niques to prevent and treat disease-related malnutrition of both
inpatients and out-patients [75]. [Strong Consensus, 97%
agreement]
3.4.4. Obesity and other disease-specific support teams
In addition to Nutrition Support Teams (NSTs) that usually
works across all hospital departments, disease or condition
A NST is a multi-disciplinary team of physicians, dietitians,
nurses and pharmacists. Other relevant professionals may also be
part of the NST, e.g. physiotherapist and speech therapists.
The main objective of the NST is to support hospital staff in the
provision of nutrition therapy, especially enteral or parenteral
nutrition, to ensure that the nutritional needs of patients are
satisfied, especially for those patients with complicated nutritional
[Strong Consensus, 97% agreement]
3.5. Forms of nutritional care
Nutrition care and therapy can be provided in many ways
(Table 7).
3.5.1. Meal environment
3.5.1.1. Meal support. Meal support is specific efforts to promote
food intake, which encompasses friendly social interactions with
the caring staff as well as with other patients or residents during
mealtimes. Suitable meal-time ambiance contributes to a relaxed
and comfortable environment. The atmosphere or the perception of
the entirety of the meal is the product of both material and
immaterial factors. Protected mealtimes, i.e. not allowing medical
or caring procedures to take place during themeal, is a further meal
support action to promote oral intake [76,77]. Patients' choice from
a la carte menus and meals-on-demand are increasingly offered
[78]. [Strong Consensus, 100% agreement]
3.5.1.2. Eating support. Eating support encompasses actions to
enable an individual to eat through verbal encouragement and
physical support. Eating support prioritizes a number of factors
such as positioning at the table, provision of assistive eating tools,
assistance with cutting the food in smaller pieces, and helping
patients to make informed food choices [76,79]. [Strong Consensus,
100% agreement]
3.5.2. Diets
Dietary advice and counselling about food choices and prepa-
rations may be relevant for patients, relatives and informal care-
givers concerning all below described types of diets.
3.5.2.1. Regular hospital diet. Regular hospital diet should cover
individual patient's nutrient and energy requirements according to
recommendations based on scientific evidence. Diet composition
takes local food habits and food patterns into account as long as
there are no specific therapeutic requirements, in which cases a
therapeutic diet or functional food is required (see below). [Strong
Consensus, 97% agreement]
3.5.2.1.1. Food product. A food product is any food that is suit-
able for human consumption whichprovides energy-containing
macronutrients (e.g. carbohydrates, protein, fats), and/or micro-
nutrients (e.g. vitamins, minerals), and/or other substances which
may contribute to fulfil the nutritional requirements of the patient.
[Strong Consensus, 100% agreement]
3.5.2.2. Therapeutic diet. Therapeutic diets are prescribed accord-
ing to the specific need of the patient.
3.5.2.2.1. Food modification. Some conditions or disorders, e.g.
diabetes mellitus, hyperlipidaemia, hepatic encephalopathy, renal
or celiac disease may require food modifications that could include
adjustments of carbohydrate, fat, protein and micronutrient intake,
or the avoidance of specific allergens. [Strong Consensus, 97%
agreement]
3.5.2.2.2. Fortified food. Fortified food is food products to which
vitamins, minerals, energy or other nutrients, or a combination of
them, have been added to increase energy or nutrient density.
[Strong Consensus, 97% agreement]
3.5.2.2.3. Food supplements. Food supplements are food prod-
ucts that supplement normal diet and which are concentrated
sources of nutrients (e.g. vitamins or minerals) or other substances
with a nutritional or physiological effect, alone or in combination,
marketed in various dose forms: capsules, tablets and similar
forms, sachets of powder, ampoules of liquids, drop dispensing
bottles, and other similar forms oral dosage forms, liquids and
utrition 36 (2017) 49e64
powders designed to be taken in measured small unit quantities
(https://www.efsa.europa.eu/en/topics/topic/supplements).
[Strong Consensus, 100% agreement]
3.5.2.2.4. Functional food. Functional food is food fortified with
additional ingredients or with nutrients or components intended to
yield specific beneficial health effects. [Strong Consensus, 100%
agreement]
3.5.2.2.5. Texture modified food and thickened fluids.
Texture modified food and thickened fluids can be available in
several various qualities. Although there are no harmonised de-
scriptors they could be described as follows [80]:
- Liquidized/thin pur�ee; Homogenous consistency that does not
hold its shape after serving.
- Thick pur�ee/soft and smooth; Thickened, homogenous consis-
tency that holds its shape after serving and does not separate
into liquid and solid component during swallowing, i.e.,
cohesive.
- Finely minced; Soft diet of cohesive, consistent textures
requiring some chewing (particle size most often described as
0.5 � 0.5 cm).
- Modified normal; Normal foods of varied textures that require
chewing, avoiding particulate foods that pose a choking hazard
(particle size most often described as 1.5 � 1.5 cm). [Strong
Consensus, 97% agreement]
T. Cederholm et al. / Clinical N
Table 7
Overview of forms and products for nutritional care and therapy.
� Meal environment
➢ Meal support
➢ Eating support
� Diets
➢ Regular hospital diet
▪ Food product
➢ Therapeutic diet
▪ Food modification
▪ Fortified food
▪ Food supplements
▪ Functional food
▪ Texture modified food and fluid
� Medical nutrition therapy
➢ Oral nutritional supplements (ONS)
▪ Nutritionally complete ONS
▪ Nutritionally incomplete ONS
➢ Enteral tube feeding/enteral nutrition
▪ Total
▪ Supplemental
▪ Home
➢ Parenteral nutrition
▪ Total
▪ Supplemental
▪ Home
▪ Subcutaneous fluid therapy
▪ Intra-dialytic
� Palliative nutrition
3.5.3. Medical nutrition therapy
Medical nutrition therapy is a term that encompasses oral
nutritional supplements, enteral tube feeding (enteral nutrition)
and parenteral nutrition. The two latter has traditionally been
called artificial nutrition, but this term is suggested to be replaced
by medical nutrition therapy.
Nutrition products that are delivered via the gastrointestinal
tract, i.e. provided orally or as tube feeding, are defined in the EU
legislation as “foods for special medical purposes” (FSMPs)
(Directive on foodstuffs intended for PARticular NUTritional useS
2009/39/EC 2013/609/EC (PARNUTS) [81,82]. FSMPs are defined as
“specially processed or formulated and intended for the dietary
[Strong Consensus, 96% agreement]
management of patients, including infants, to be used under
medical supervision; it is intended for the exclusive or partial
feeding of patients with a limited, impaired or disturbed capacity to
take, digest, absorb, metabolise or excrete ordinary food or certain
nutrients contained therein, or metabolites, or with other
medically-determined nutrient requirements, whose dietary
management cannot be achieved by modification of the normal
diet alone” - Regulation (EU) no 609/2013 of the European parlia-
ment and of the council. The PARNUTS directive will be replaced by
the FSG regulation 2013 (Regulation on Food for Specific Groups),
supplemented by delegated regulation (EU) 2016/128 on FSMP.
[Strong Consensus, 100% agreement]
3.5.3.1. Oral nutrition therapy. Oral nutrition therapy is mainly
given as oral nutritional supplements (ONS) and defined as FSMP
(see above). ONS are developed to provide energy and nutrient-
dense solutions that are provided as ready to drink liquids,
cr�emes or powder supplements that can be prepared as drinks or
added to drinks and foods. Liquid ONS (either ready to drink or
made up from powders) are sometimes referred to as sip feeds.
Clinical effects and cost-effectiveness are well established [83e85].
[Strong Consensus, 97% agreement]
3.5.3.2. Enteral tube feeding. Synonym: enteral nutrition.
Enteral tube feeding is nutrition therapy given via a tube or stoma
into the intestinal tract distal to the oral cavity. Enteral formulas are
defined as FSMP (see above). The tube could be inserted via the
nose; i.e. naso-gastric, naso-jejunal or naso-post pyloric tube
feeding; or via a stoma that is inserted endoscopically into the
stomach; i.e. percutaneous endoscopic gastrostomy (PEG) or with a
jejunal extension (PEG-J) or into the jejunum (percutaneous
endoscopic jejunostomy (PEJ)). Finally, the tube may also be placed
surgically; i.e. surgical gastrostomy or jejunostomy. [Strong
Consensus, 97% agreement]
3.5.3.2.1. Total enteral tube feeding. Synonym: total enteral
nutrition (TEN). Total enteral tube feeding (TEN) refers to condi-
tions when all nutrient needs are provided through a feeding tube
without significant oral or parenteral intake. [Strong Consensus,
97% agreement]
3.5.3.2.2. Supplemental enteral tube feeding. Supplemental
enteral tube feeding is nutrition given to patients whose oral intake
of food and fluids is inadequate for reaching their defined
target alone. [Strong Consensus, 97% agreement]
3.5.3.2.3. Home enteral tube feeding. Synonym: Home Enteral
Nutrition (HEN). When enteral tube feeing is used outside the
hospital it is called Home Enteral Nutrition (HEN) or as in some
countries Home Enteral Tube Feeding (HETF). It can be provided
either as total or supplemental enteral nutrition. [Strong
Consensus, 100% agreement]
3.5.3.3. Parenteral nutrition (PN) therapy. Parenteral nutrition is a
type of nutrition therapy provided through intravenous adminis-
tration of nutrients such as amino acids, glucose, lipids, electrolytes,
vitamins and trace elements. PN can be central through a central
venous line, or peripheral through a peripheral intravenous line.
[Strong Consensus, 97% agreement]
3.5.3.3.1. Total parenteral nutrition (TPN). Synonym: exclusive
parenteral nutrition. Total parenteral nutrition (exclusive paren-
teral nutrition) therapy refers to situations where the patient's
complete nutritional needs (all macro and micro-nutrients) are
covered by the PN, and in which nutrition is not given by any route
other than intravenously. [Strong Consensus, 100% agreement]
3.5.3.3.2. Supplemental parenteral nutrition (SPN). Synonym:
partial parenteral nutrition or complementary parenteral nutrition.
utrition 36 (2017) 49e64 59
Supplemental (partial or complementary) parenteral nutrition
al N
refersto situations where nutrition is provided in addition to
parenteral nutrition by any route other than intravenously. For
example, this situation may arise when the oral or enteral tube
routes cannot independently achieve the defined nutritional care
plan target (See Section 3.3.4). [Strong Consensus, 100% agreement]
3.5.3.3.3. Home Parenteral Nutrition. When parenteral nutrition
is used outside the hospital it is called Home Parenteral Nutrition
(HPN). HPN used as TPN or SPN is often used for patients with
chronic intestinal failure, malignant obstruction or partial
obstruction of the gastrointestinal tract [86]. [Strong Consensus,
100% agreement]
3.5.3.3.4. Subcutaneous fluid therapy. The subcutaneous route is
a special parenteral route primarily used to provide fluids (hypo-
dermoclysis). It can also be used to provide limited amounts of
glucose and amino acids, when the intravenous route is unavailable
or unsuitable. It is mainly used in late life care. [Consensus, 87%
agreement]
3.5.3.3.5. Intra-dialytic parenteral nutrition (IDPN). IDPN is PN
given intravenously through the venous line of the dialysis circuit,
and thus given cyclic during the dialysis session [87]. IDPN is not a
routine technique for supplemental nutrition therapy, but may be
indicated to prevent nutritional deterioration in patients receiving
dialysis treatment when other methods of nutrition therapy have
proved insufficient to meet nutritional and metabolic needs [88].
[Strong Consensus, 97% agreement]
3.5.4. Palliative nutrition
Palliative nutrition is the form of nutritional care and therapy
that is provided to patients in late phases of end-stage disease. The
major goal is to improve quality of life [89]. Food or nutrient re-
strictions are avoided. The nutrition measures are decided by the
palliative phase. In the early phase energy, proteins and nutrients
are provided by the best feasible route. In late phase of palliative
care psycho-social support around meals and food intake for both
the patient and relatives is prioritized. Parenteral nutrition could be
considered to reduce stress around the meal situation. Monitoring
of the nutritional status, e.g. recording weight changes, should be
avoided to not addmore stress during the final phase of life. [Strong
Consensus, 94% agreement]
3.6. Nutritional products for medical nutrition therapy
3.6.1. Oral nutritional supplements (ONS)
There are two major types of ONS; those that are nutritionally
complete and those that are nutritionally incomplete.
3.6.1.1. Nutritionally complete ONS. These are standard ONS that
can be used as the sole source of nourishment for prolonged pe-
riods since they have a balanced nutritional composition of macro-
and micronutrients, including essential amino acids, essential fatty
acids and micronutrients that reflect dietary recommendations for
healthy people. They are commonly used as a supplement to the
general diet, when the regular food intake is insufficient. Nutri-
tionally complete standard ONS can in some cases represent the
only source of intake of energy and nutrients. [Strong Consensus,
100% agreement]
3.6.1.2. Nutritionally incomplete ONS. These are not suitable for use
as the sole source of nutrients since they are adapted to contain
some specific nutrients in higher amounts, whereas the content of
other nutrients is lacking or insufficient.
Disease-specific ONS are modified in order to meet specific
nutritional andmetabolic demands for certain diseases for example
T. Cederholm et al. / Clinic60
diabetes, pressure ulcers, cirrhosis, cancer, renal failure and
pulmonary disease, and can be complete or incomplete. [Strong
Consensus, 94% agreement]
3.6.2. Enteral formulas
Standard enteral formulas have a composition that meets the
nutritional needs of the general population. In general, energy,
protein and micronutrient needs are covered by 1.5 L of standard
enteral formula. They can have a standard nutrient profile or can be
nutrient adapted for certain conditions or diseases. Most standard
enteral formulas (and their high energy and high protein variants)
contain fibre and are free of lactose and gluten. Whole protein
formulas contain intact proteins, and typically contain lipids that
are mostly provided in the form of long chain triglycerides, and
carbohydrates that come predominantly as polysaccharides, e.g.
maltodextrin. Enteral formulas are mostly nutritionally complete.
Formulas containing peptides and medium chain triglycerides
can facilitate absorption in case of e.g. malabsorption or short
bowel syndrome.
Disease specific enteral formulas are designed to meet specific
nutritional and metabolic demands, for example for patients with
diabetes, pressure ulcers, cirrhosis, cancer, renal failure and pul-
monary disease. [Strong Consensus, 94% agreement]
3.6.3. Parenteral solutions
Parenteral solutions are composed of carbohydrates (glucose),
lipids and amino acids and can include electrolytes, vitamins and
trace elements as required. They are defined by the relative
composition of the macronutrients, osmolarity, pH and calorie
content. These solutions can be administered using separate bottles
but are preferably administered using compounding or ready to
mix bags. [Strong Consensus, 94% agreement]
3.6.3.1. Parenteral nutrition. Parenteral nutrition infusates for
parenteral administration are intended to provide energy and nu-
trients, rather than hydration alone. They are usually given intra-
venously. PN infusates can aim to provide a single group of
nutrients (e.g. the use of lipid emulsion alone) or a combination of
nutrients that is more typically thought of as a PN infusate (e.g. a
combination of amino acids, glucose, lipid emulsion, electrolytes
and vitamins and trace elements in Water for Injection). [Strong
Consensus, 93% agreement]
3.6.3.1.1. Three chamber bag/all-in-one PN. A three chamber bag
(usually industry manufactured) or all-in-one (mainly pharmacy
provided) PN infusate is an emulsion in which amino acids, glucose
and lipid emulsion are combined in a single infusate, along with
electrolytes, vitamins and trace elements as required.
Three-chamber bags contain all macronutrients and electrolytes
in three separate compartments. The substrates are mixed together
immediately prior to intravenous application by breaking the
separation seals between the bag chambers. Three chamber bags
are available with or without basic electrolytes. Vitamins and trace
elements are injected into the bag prior to administration. This can
be a relatively safe system for PN administration, e.g. the risk of
infection is lowered by the closed system and by reduced
manipulation.
Individually compounded all-in-one (AIO) admixtures allow for
the provision of patient-specific ready-to-use PN infusates, adapted
according to energy, volume and substrate needs. These are asep-
tically manufactured from various components, usually in hospital
pharmacies, and are designed for immediate intravenous admin-
istration, with no mixing or admixing required prior to adminis-
tration. These bags are usually compounded daily or weekly due to
their often limited stability. They require appropriate storage under
utrition 36 (2017) 49e64
refrigeration at 2e8 �C prior to use, but should be gently warmed to
types of container (e.g. glass or plastic), or with the intended
tion/undernutrition [7]. A similar measure to define diagnostic
al N
electrolyte available as different salts. These differences lead to a
number of considerations such as potential container contami-
nants, ordering and storage requirements (e.g. in some cases with
high strength potassium solutions), conversion between different
units, and differences in stability assessment when electrolyte so-
lutions are combined with other components (e.g. the use of inor-
ganic compared to organic salts).
For parenteral nutrition a standard